Reactive Attachment Disorder
No. 85; Updated May 2008
Reactive Attachment Disorder (RAD) is a complex psychiatric illness that can affect young children. It is characterized by serious problems in emotional attachments to others. RAD usually presents by age 5, but a parent, caregiver or physician may notice that a child has problems with emotional attachment by their first birthday. Often, a parent brings an infant or very young child to the doctor with one or more of the following concerns:
* severe colic and/or feeding difficulties
* failure to gain weight
* detached and unresponsive behavior
* difficulty being comforted
* preoccupied and/or defiant behavior
* inhibition or hesitancy in social interactions
* disinhibition or inappropriate familiarity or closeness with strangers.
The physical, emotional and social problems associated with RAD may persist as the child grows older.
Most children with Reactive Attachment Disorder have had severe problems or disruptions in their early relationships. Many have been physically or emotionally abused or neglected. Some have experienced inadequate care in an institutional setting or other out-of-home placement (for example a hospital, residential program, foster care or orphanage). Others have had multiple or traumatic losses or changes in their primary caregiver. The exact cause of Reactive Attachment Disorder is not known.
Children who exhibit signs of Reactive Attachment Disorder need a comprehensive psychiatric assessment and individualized treatment plan. These signs or symptoms may also be found in other psychiatric disorders. A child should never be given this label or diagnosis without a comprehensive evaluation.
Treatment of this complex disorder involves both the child and the family. Therapists focus on understanding and strengthening the relationship between a child and his or her primary care givers. Without treatment, this condition can affect permanently a child's social and emotional development. However, unconventional and forced treatments such as "rebirthing" strategies are potentially dangerous and should be avoided.
Parents of a young child who shows signs or symptoms of Reactive Attachment Disorder should:
* seek a comprehensive psychiatric evaluation by a qualified mental health professional prior to the initiation of any treatment
* make sure they understand the risks as well as the potential benefits of any intervention
* feel free to seek a second opinion if they have questions or concerns about the diagnosis and/or treatment plan
Reactive Attachment Disorder is a serious clinical condition. Fortunately, it is relatively rare. Evaluating and treating children with complex child psychiatric disorders such as Reactive Attachment Disorder is challenging. There are no simple solutions or magic answers. However, close and ongoing collaboration between the child's family and the treatment team will increase the likelihood of a successful outcome.
(Source found on American Academy of Child & Adolescent Psychiatry)
(http://www.aacap.org/cs/root/facts_for_families/reactive_attachment_disorder)
Strategies on how to handle a student with Reactive Attachment Disorder
Step 1
Talk to the child's parents. They may have some useful strategies for managing the child's behavior. It is important to phone or email directly, since notes sent home with the child will probably not get to the parents. Let the child know that you will be in frequent contact with her parents.
Step 2
Know that children with RAD need a different type of teaching. Traditional behavior plans such as getting stickers or treats for good behavior won't work because the RAD child will just figure out how to work the system. They do not care about your approval.
Step 3
Acknowledge good decisions and good behavior. Be specific in your praise. Avoid saying general things like, "You were a good girl today." Such non-specific praise won't mean anything to the RAD child. Do not attach good behavior to a tangible reward. Again, traditional behavior management plans don't work.
4.
Step 4
Administer consequences for poor decisions and behavior. Remain calm and in control of your emotions when you do this. He is trying to provoke a negative response from you and will feel as though he's won if you get angry. Similarly, avoid "I statements," such as "I'm disappointed that you did that." If you do get upset (as you are bound to do sometimes), remove yourself or the child from the situation until you have regained control of your emotions. Avoid using a traditional time-out for the child, though, as their goal is to isolate themselves.
Step 5
Teach them about choices. These children do not understand cause and effect. Explicitly point out choices they are making, i.e. "You are choosing to distract others from their work." This is a difficult concept for the RAD child, but once you make some headway on this, you can teach them about good choices and bad choices.
Step 6
Get help. Learn more about RAD (see Resources). The parents may be able to help you both with RAD resources and what has worked for their child. The school psychologist, counselor or social worker might also be able to help with interventions.
Step 7
Avoid losing faith in yourself. The child did not become this way overnight, and you cannot be expected to change her overnight. She will, in fact, require extensive therapy and support from the parents and school in order to turn things around and lead a healthy, happy and productive life.
(Source Ehow.com)
(http://www.ehow.com/how_2205074_child-reactive-attachment-disorder-classroom.html)
Two excellent resources for educators are:
ReplyDeleteAttachment in The Classroom by Heather Geddes
Inside I'm Hurting (don't have the author's name off-hand).
In addition, my website has a handout for teachers that parents may find useful:
http://www.center4familydevelop.com/helpteachrad.htm
What follows is the handout
ReplyDeleteAn Overview of Reactive
Attachment Disorder for Teachers ShareThis
If a parent has given you this to read, you are teaching a child with Reactive Attachment Disorder. The family of this child has apparently decided to share this information with you. That sharing is a big step for this family and one you have to treat gently and with the respect it deserves.
Reactive Attachment Disorder (RAD) is most common in foster and adopted children but can be found in many other so-called "normal" families as well due to divorce, illness or separations. Reactive Attachment Disorder (RAD) develops when a child is not properly nurtured in the first few months and years of life. It is causes by early chronic maltreatment such as neglect, abuse, or institutional care. The child, left to cry in hunger, pain or need for cuddling, learns that adults will not help. The child whose parent(s) are more involved in getting their next drug fix than they are in nurturing the developing child learns that the child’s needs are not primary to the caregivers. Children born of drug or alcohol addicted parents learn even in the womb that things do not feel good and are not safe for them. In severe cases, where the child was an abuse or violence victim, the child learns adults are hurtful and cannot be trusted. The child with RAD may develop approaches or “working models” of the world to keep the child safe. The child may try to control a world the child experiences as dangerous if not controlled by the child. Without therapy child with RAD may not develop the attachments to other human beings which allow them to trust, accept discipline, develop cause and effect thinking, self-control and responsibility.
Children with RAD are often involved in the Juvenile Justice System, as they get older. They feel no remorse, have no conscience and see no relation between their actions and what happens as a result because they never connected with or relied upon another human being in trust their entire lives.
What you may see as a teacher is a child who is, initially, surprisingly charming to you, even seeking to hold your hand, climbing into your lap, smiling a lot, you're delighted you are getting on so well with such a child. At the onset of your contact with the child who has been reported from prior grades as "impossible" you will wonder what those previous teachers did to provoke the behaviors you have not (yet) seen but which are reflected in the prior grade reports. A few months into what you thought was a working relationship the child is suddenly openly defiant, moody, angry and difficult to handle; there is no way to predict what will happen from day to the next; the child eats as if he hasn't been properly fed and is suspected of stealing other children's snacks or lunch items; the child does not seem to make or keep friends; the child seems able to play one-on-one for short periods, but cannot really function well in groups; the child is often a bully on the playground; although child with RAD may have above average intelligence they often do not perform well in school due to lack of problem solving and analytical thinking skills; they often test poorly because they have not learned cause-effect thinking. In addition, having experienced at an early age that nothing they do matters, they do not “try” or put in effort; why try when what you do has not effect?
A child with RAD may climb into your lap and pretend to be affection starved. Children with RAD may talk out loud in classrooms, do not contribute fairly to group work or conversely argue to dominate and control the group. Organizational abilities are limited and monitoring is resented. There may be a sense of hypervigilance about them that you initially perceive as no sense of personal space and general "nosiness". They seem to want to know everyone else's business but never tell you anything about their own. There is no sense of conscience, even if someone else is hurt. They may express an offhand or even seemingly sincere "sorry,” but will likely do the same thing again tomorrow. They are not motivated by self or parental pride, normal reward and punishment systems simply do not work.
They may omit parts of assignments even when writing their names just so that they are in control of the assignment, not you. This stems from a deep feeling that adults are not to be trusted, so the best strategy when you don’t trust someone may be to not do what that person asks you to do. When assigned a seat they may choose an indirect, self- selected path to reach the seat. When given a certain number of things to repeat or do, they often do more, or less than directed. They destroy toys, clothing, bedding, pillows, and family memorabilia. They may blame parents, siblings, or others for missing or incomplete homework, missing items of clothing, lost lunch bags, etc. They may destroy school bags, lose supplies, steal food, sneak sweets, break zippers on coats, tear clothing, and eat so as to disgust those around them (open mouth chewing, food smeared over face).
They may inflict self-injuries, pick at scabs until they bleed, seek attention for non-existent/miniscule injuries, and yet will seek to avoid adults when they have real injuries or genuine pain. These children have not learned how to seek and accept comfort and care from caregivers because their early experiences have taught them that adults don’t care. Children with RAD may have multiple falls and accidents and frequently complain about what other children have done to them ("he started it!", "Suzy kicked me first"). Children with RAD can walk around in significant physical pain from real injuries and may minimize the injury until it is detected. They may not wipe a running nose or cover a mouth to sneeze or conversely will overreact or exaggerate a cough or mild illness. They often have not had experiences of being taught in a loving responsive manner how to wash, bathe, brush teeth, and engage in other self-care activities.
They are in a constant battle for control of their environment and seek that control however they can, even in totally meaningless situations. If they are in control they feel safe. If they are loved and protected by an adult they are convinced they are going to be hurt because they never learned to trust adults, adult judgment or to develop any of what you know as normal feelings of acceptance, safety and warmth. Their speech patterns are often unusual and may involve talking out of turn, talking constantly, talking nonsense, humming, singsong, asking unanswerable or obvious questions ("Do I get a drink any time today?"). They have one pace – theirs. No amount of "hurry up everyone is waiting on you" will work – they must be in control and you have just told them they are. Need the child to finish lunch so everyone can go to the playground. Need the child to dress and line up, the child may scatter papers, drop clothing, fail to locate gloves, wander around the room – anything to slow the process and control it further. Five minutes later the child may be kissing your hand or stroking your cheek for you with absolutely no sense of having caused the mayhem that ensues from his actions. Again all these behavior are NOT intentional. The behaviors are the result of having experienced significant early chronic maltreatment. These early experiences have created an internal working model of the world and relationship that mirror those early experiences and which are projected onto current relationships.
You can begin to understand what this child's parents must face on a daily basis. The parents are often tense; involved in control battles for their parental role every minute they are with the child, they adopted the child thinking love would cure anything that had happened to her before the adoption. They have only recently learned that normal parenting will not work with this child; that much of what they have tried to do for years simply fed into the child's dysfunction. They are frightened, sad, stressed and lonely. Many feel unmerited guilt for their perceived "failure" with this child. The mothers often bear the brunt of the child's actions.
It takes a tremendous amount of work and therapy to turn these kids around so that they can experience real feelings and learn to trust. Parents who have embarked on this healing journey for their child need support and consistency from other adults who interact with the child.
What can you do as a teacher? CALL THE PARENTS. Have them in to talk with you about this issue. Call them and talk about what you see in the classroom and ask if they have any other strategies for managing things. Parents who are in counseling and therapy with this child will eventually open up to you and you'll all be able to help the child get healthy or at least not contribute to his dysfunction.
Parents will tell you if time is precious on a particular occasion due to ongoing therapy, or whatever, don't feel put off or shut out. They will talk to you when they have time and time is one of the things parents often run out of as they work desperately to save their child's future. The therapy and home parenting techniques are exhausting and time consumptive. Try to respect that if it seems they are not focusing on your goal of home or class work. Do not trust schoolbag communication or expect things sent in a "communication envelope" to be as complete as when they left the school with the child. Use the phone, e-mail, and regular mail – it works.
Don't feel you need to apologize if you have believed this child and blamed the parents. If they have given you this information they already trust you and do not blame you for not having the information you needed – likely they only just recently got it themselves. Make it perfectly clear in your interactions with the child that you will take care of the child and the classroom or activity. Remind the child, unemotionally but firmly, that you are the teacher, you make the rules. You can even smile when you say it if you can get the "smile all the way up to the eyes", just remember to get the child to verbally acknowledge your position. Do it every day for a while, and then use periodic reminders. Insist upon use of titles or prefixes (Miss Jane, Teacher Sarah, Ms. Philips), they establish position and rank. Structure choices so that you remain in control ("do you want to wear your coat or carry it to the playground?” "you may complete that paper sitting or standing", "you may complete that assignment during this period or during recess"). Remember to keep the anger and frustration the child is seeking out of your voice. Try to "smile all the way to your eyes" if you can, otherwise simply stay as neutral as you can. Structure and control without threat.
YOU ARE NOT THE PRIMARY CAREGIVER for this child. You cannot parent this child. You are the child’s teacher, not therapist, nor parent. Teachers are left behind each year, its normal. These children need to learn that lesson.
Establish EYE CONTACT with this child. Be firm, be consistent, and be specific.
Try to remember to ACKNOWLEDGE GOOD DECISIONS AND GOOD BEHAVIOR
CONSEQUENCE POOR DECISIONS AND BAD BEHAVIOR. Poor decisions and choices like incomplete homework, wrong weight jacket for the weather, also need to be acknowledged ("I see you didn’t complete work from this activity period. You may finish it at recess while the other children who chose to finish their work go outside and play.") Nothing mean or angry or spiteful – it's just the facts. Remember they have difficulty with cause and effect thinking and have to be taught consequences. Normal reward systems like treats and stickers simply do not work with these children. Standard behavior modification techniques do not work with this child.
Consequencing is a good teaching technique– there is a consequence associated with each good behavior, each poor behavior – teach them what those consequences are – they will not think of or recognize them without your direction.
BE CONSISTENT, BE SPECIFIC. The child with RAD may be "good" for you one or two days or even weeks and then fall apart. This is normal. No general compliments like "you're a good boy!" or "You know better.” Be specific and consistent – confront each misbehavior and support each good behavior with direct language. "You scribbled on the desk – you clean it up", "You hit Timmy, you sit here next to me until I decide you may play again without hitting." "You did well on the playground today, good for you!” "You completed that assignment, that's a good choice!” Be positive when you can.
This NATURAL CONSEQUENCES thing is important. Do not permit this child to control your behavior by threatening to throw a tantrum (let him, out in the hallway or in another room -"You can have your tantrum here if you choose to"), "I see you've wet the rug, here is a rag and bucket to clean it up", or puttering around doing his own thing when it delays the class' departure for a planned activity ("I see you've not gotten ready to go, you can wait here in the supervisor's office until we get back").
Time-outs do not work for these children – they want to isolate themselves from others. Bring the child near the activity he has had to be removed from and have them stand with or sit in a chair along side you. It's called a "TIME-IN.” If you can take the time, speak quietly about how much fun the other children are having and how sad it is that she cannot join in right now. No raised voices, no anger. Don't lose your temper if you can avoid it; remember he is manipulating you to do just that. If you are going to lose it, seek assistance from another adult until you are back in control of yourself.
RESPONSIVE, ATTUNED, EMOTIONALLY ENGAGED INTERACTIONS with this child. It is very important that this child experience positive regard and that the child is good, even is the behavior is not acceptable. This helps the child move from feeling overwhelming shame to experiencing guilt.
SUPPORT THE PARENTS. The child who is losing control at home and in the classroom because folks are "on to him" will get a whole lot worse before he gets better. Listen appropriately. Absolutely redirect this child to parents for choices, hugs, decision-making and sharing of information you believe is either not true or is designed to shock or manipulate you. Follow up with the parents.
REMAIN CALM AND IN CONTROL OF YOURSELF. No matter what the child does today. If the child manages to upset you, the child is in control, not you. Remove yourself or the child from the situation until you are able to cope. The child may push your “buttons.” But remember, these are YOUR buttons and it is your job as a professional to disconnect the buttons so that pressing them has no negative effect.
If your classroom is out of control because of this child, get help. Many school counselors and administrators have not had exposure to the RAD diagnosis or how to handle it in schools. There are many resources available. Don't give up. These children are inventive, manipulative and very much in need of everything you can offer to help them get healthy. Remind the child you will be speaking with her parents on a regular basis. Report to the child's home as often as you can without feeling burdened by the effort. Expect notes to be destroyed. Use the phone. If you do not get a response to written communication and the parents seem to be out of touch with general information, do not blame them. Chances are they never got the message, never saw the right number of papers and have no clue what is going on because that is just how the child likes it. It takes control from the parent. Give it back by communicating directly whenever possible.
This child can and will be helped to get healthy and you can be a part of that process with the right tools. Keep in touch with the family. Remember that what you see in school is only the tip of the iceberg – family life is terribly threatening to these children and what the parents have to deal with every day is nearly unimaginable to other uninformed adults. Blaming the family or failing to communicate with them adds to the dysfunction and puts the child at greater risk of never getting healthy. This child is learning in therapy to be respectful, responsible and fun to be around. It will take time, it will be an effort, if in the end it is successful it will be because the adults in her life were consistent and the child decided to work in therapy. Your contribution as his teacher cannot be underestimated or undervalued – his parents will be grateful for the support and the therapist will have fewer inconsistent venues to sort out while helping the child to heal.
BOOK AND RESOURCES
Creating Capacity for Attachment, Edited by Arthur Becker-Weidman & Deborah Shell, Wood ‘N’ Barnes, Oklahoma City, OK, 2005.
Attachment Facilitating Parenting video/DVD. Center for Family Development, Arthur Becker-Weidman, Ph.D., 5820 Main St., #406, Williamsville, NY 14221
Building the Bonds of Attachment, 2nd. Edition, Daniel Hughes, Jason Aaronson, NY, 2006.
www.ATTACh.org
WWW.Center4FamilyDevelop.com
Reactive attachment disorder, term is used to describe a condition that generally appears in the children before age 5, and is thought to result from a lack of consistent care and the nurturing in early years. The disorder is characterized by the inability of a child or infant to establish age appropriate social contact and relationships with the others.
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